EquiTrauma: Providing access to equitable trauma care in lower and middle income countries

NIHR trauma project news

The University of Birmingham team have created and delivered bespoke training for their colleagues in Ghana, South Africa and Rwanda in the areas of research skills and research management. This training is an important part of strengthening our relationship and successful collaboration with partners.

Qualitative research training: 28^th September – 1^stOctober 2020.

Training of research assistants in South Africa and Rwanda

On 23^rd November 2020, the NIHR trauma project team at the University of Birmingham rolled out the second phase of qualitative training for the Research Assistants at the partner universities in Ghana, South Africa and Rwanda. In this session we focused on analysing data from key informant interviews and focus group discussions using NVIVO.

Our partners in Ghana, conducting socially distanced focus group discussion at the Yendi Municipal Hospital on access to care for injured people. During the field visit, the team encountered a patient with strangulated inguinal hernia and decided to operate on him before heading back to the Northern Regional capital in Tamale.

Great to see the level of enthusiasm exhibited by the team to understand barriers to trauma care access in Ghana even during the Covid 19 pandemic. The pandemic may have slowed the project but haven’t affected the tenacity of the team to deliver quality data.

December 17, 2020, our team at the University of Birmingham held the last meeting for 2020 with all project partners from Ghana, Rwanda and South Africa to review the NIHR funded project activities on trauma care for the year. The meeting offered us the opportunity to reflect on the successes as well as challenges during the year to guide plans in the year ahead.

Mapping barriers in access to injury care in South Africa

On 11 March 2021, our South African team held a workshop with healthcare providers, stakeholders and patients to map barriers in access to injury care in South Africa. In total, there were 34 participants and the workshop was conducted according to local rules using protective equipment and social distancing.

Altogether 49 barriers in access to injury were identified by the participants and the top prioritised barriers were; 1. Socioeconomic factors making it difficult to reach care, 2. Lack of resources at facilities, 3. Perceived waiting period at health facilities and 4. Lack of access to radiology services after closing hours.

We are very proud to be working with such a great team in South Africa that managed to organise this workshop during these difficult Covid times.

Workshop on access to injury care in Tamale, Ghana

The first week of May we travelled to one of our data collections sites in Tamale, Ghana, to host our last workshop on access to injury care. We also had our end of grant investigator meeting with all the principal investigators and research assistants from each country. Colleagues (including Deans of three medical schools) from Ghana, Rwanda, and South Africa were present. It was a great final meeting where we had all the results from each country presented by the data collectors. We discussed the findings, came to consensus on important barriers in access to injury care and agreed on the next steps.

 

Reducing deaths from trauma is a key Sustainable Development Goal (SDG 3.6), as is providing Universal Health Coverage (UHC: SDG 3.8). 

Currently, trauma accounts for more deaths than TB, malaria and HIV combined, with 90% of these deaths occurring in LMICs; trauma associated mortality is due to rise with projections that road traffic collisions will be the third leading cause of death by 2030 (they currently are the top killer for people 5-29 years old).

Amongst trauma patients, timely access to quality care remains inequitable, with gaps in health services leading to barriers to care seen amongst those who are the poorest or otherwise vulnerable. Whilst reducing the occurrence of trauma is necessary, the universal provision of health systems to treat the inevitably injured is also required to improve health, wellbeing, and economic prosperity.

This project seeks to delineate barriers in access to trauma care in order to develop future interventions to ensure equitable access to trauma care for all. 

This project draws on the growing partnerships between University of Rwanda, University of Global Health Equity (Rwanda), Stellenbosch University (South Africa), University for Development Studies (Ghana) and University of Birmingham.  At the University of Birmingham, the project draws upon the strengths of the Institute of Applied Health Research in collaboration with the NIHR Surgical Reconstruction and Microbiology Centre (NIGR SRMRC), the Centre for Precision Rehabilitation for Spinal Pain (CPR Spine) and the Department for Political Science and International Studies on Global Health and Trauma Research. In this project we will delineate barriers that are causing delays in access to trauma care in Rwanda, Ghana and South Africa in order to make plans for future interventions. We will use qualitative methods to explore barriers in access to trauma care in rural and urban communities. Additionally, we will do workshops gathering service users, service providers, researchers and policy makers to develop context specific interventions to improve access to quality care for all. 

This qualitative and priority setting study will be done in one rural and one urban area in three countries; Ghana, South Africa, and Rwanda

Amongst trauma patients, timely access to quality care remains inequitable with gaps in health services leading to barriers to care seen amongst those who are the poorest or otherwise vulnerable. Non-fatal trauma is important and common. Most trauma studies have focused on care received in the facility (usually tertiary referral centre) setting. However, good trauma care requires that the patients seek, reach, receive, and remain in quality care. Unfortunately, very little evidence exists of the identity and extent of these barriers, solutions to overcome them, and their priority in lower- and middle-income countries (LMICs.) 

To identify barriers to access to quality care for people who have been injured in Ghana, South Africa, and Rwanda.

In each country to:

1. Conduct a two day workshop with policy makers, infrastructure providers, service users and healthcare workers to identify barriers to access to quality injury care and prioritise solutions to overcome these barriers

2. Conduct focus group discussions with persons who have accessed care for injury to further explore barriers to access to care from the service user perspective

3. Conduct in-depth interviews with persons who have required injury care for themselves or their relatives to explore lived experiences of accessing healthcare for people who have been injured

4. Conduct a survey of experiences of healthcare for those who have been injured using a standardised questionnaire 

5. Conduct focus group discussions with community leaders to explore their experiences with or observations of barriers to accessing care amongst their community members

6. Convene a meeting of investigators, policy makers, and service user representatives at the end to discuss findings and outline future direction.

1. Publication in a peer reviewed journal

2. Policy briefs for reading by policy makers

3. Subsequent study protocol

Study limitations:

• This study is only being conducted in three countries and may not be applicable to all LMICs. However, we have chosen three countries in different income status categories and with different geographical positions in sub Saharan Africa to ensure transferability. 
• We are mostly focusing on qualitative data in this study which is a limitation. Quantitative data will be collected in planned future studies.
• This study only allows for exploration of barriers causing delays in access to quality care for the injured, and there is no focus on solutions. Nevertheless, the aim of this study is to create the basis for future studies with intervention design and implementation. 

Co-Investigators:

Professor Abebe Bekele

Professor Kathryn Chu

Professor Stephen Tabiri

Dr Agnieszka Ignatowicz

Dr. Maria Lisa Odland

Professor Antonio Belli

Dr. Alison Rushton

Professor Richard Lilford

Dr. Anthony Howards

Professor Fang Gao

• NIHR Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC)
• Centre of Precision Rehabilitation for Spinal Pain (CPR Spine)

Patients and the public were not directly involved in the design of this study. However, through the workshops the service users and providers will have huge input in the direction of our work and influence future research and interventions. 

Dr Teri Reynolds WHO